Raojaonarifara, E., Bonds, M.H., Miller, A.C., Ihantamalala, F., Cordier, L.F., Razafinjato, B., Rafenoarimalala, F.H., Finnegan, K.E., Rakotonanahary, R.J.L., Cowley, G., Ratsimbazafy, B., Razafimamonjy, F., Randriamanambintsoa, M., Raza-Fanomezanjanahary, E.M., Randrianambinina, A., Metcalf, C.J.E, Roche, B., and Garchitorena, A. (2021). medRxiv.
To reach global immunization goals, national programs need to balance routine immunization at health facilities with vaccination campaigns and other outreach activities (e.g. vaccination weeks), which boost coverage at particular times and help reduce geographic inequalities. However, where routine immunization is weak, an overreliance on vaccination campaigns may lead to heterogeneous coverage. Here, we assessed the impact of a health system strengthening (HSS) intervention on the relative contribution of routine immunization and outreach activities to reach immunization goals in rural Madagascar.We obtained data from health centers in Ifanadiana district on the monthly number of recommended vaccines (BCG, measles, DTP and Polio) delivered to children, during 2014-2018. We also analyzed data from a district-representative cohort carried out every two years in over 1500 households in 2014-2018. We compared changes inside and outside the HSS catchment in the delivery of recommended vaccines, population-level vaccination coverage, geographic and economic inequalities in coverage, and timeliness of vaccination. The impact of HSS was quantified via mixed-effects logistic regressions. The HSS intervention was associated with a significant increase in immunization rates (Odds Ratio between 1.22 for measles and 1.49 for DTP), which diminished over time. Outreach activities were associated with a doubling in immunization rates, but their effect was smaller in the HSS catchment. Analysis of cohort data revealed that HSS was associated with higher vaccination coverage (Odds Ratio between 1.18 per year of HSS for measles and 1.43 for BCG), a reduction in economic inequality, and a higher proportion of timely vaccinations. Yet, the lower contribution of outreach activities in the HSS catchment was associated with persistent inequalities in geographic coverage, which prevented achieving international coverage targets. Investment in stronger primary care systems can improve vaccination coverage, reduce inequalities and improve the timeliness of vaccination via increases in routine immunizations.